From the Research
The management of a colovesicular fistula from diverticulitis typically requires surgical intervention, with a one-stage procedure involving resection of the diseased colonic segment, takedown of the fistula, and primary anastomosis being the standard approach. This is based on the most recent and highest quality study available, which highlights the importance of surgical treatment in managing colovesicular fistulas 1.
Preoperative Evaluation
Before surgery, patients should undergo:
- Bowel preparation
- Receive broad-spectrum antibiotics, such as ceftriaxone 1-2g IV and metronidazole 500mg IV
- Have adequate nutritional support
- Preoperative evaluation should include CT imaging, colonoscopy to exclude malignancy, and cystoscopy to assess bladder involvement 2.
Surgical Procedure
The surgical procedure may be performed via open laparotomy or laparoscopically, depending on patient factors and surgeon expertise. The bladder defect is typically repaired with absorbable sutures in two layers, and a urinary catheter should remain in place for 7-10 days postoperatively to allow proper healing 3.
Postoperative Care
In cases of severe inflammation or patient comorbidities, a staged approach with temporary colostomy may be necessary. The use of intraoperative methylene blue bladder instillation can help limit unnecessary bladder repairs, and urinary catheters can be removed in 7 days or less if the methylene blue extravasation is negative 3.
Importance of Surgical Management
This surgical management is essential because conservative treatment rarely results in spontaneous closure of colovesicular fistulas, and ongoing communication between the colon and bladder leads to recurrent urinary tract infections, pneumaturia, and fecaluria, significantly impacting quality of life 1, 4, 5, 2, 3.